Psychiatric Nursing

Introduction

Mood disorders sometimes known as affective disorders are a major public health problem in the United States. Data indicate that mood disorders are leading cause of disease burden, morbidty and mortality worldwide. Theses illnesses involve changes in all areas including physiology, cognition and behavior. In addition to the effects of mood disorders have on individual and family suffering, interpersonal relationships, career and work productivity, and societal and health system costs, these illnesses are also sometimes fatal: 15% of those afflicted commit suicide.  Depression is also linked to morbidity and mortality when it is associated with other illnesses such as cardiovascular disease. As a result of these serious consequences, there has been ongoing research about the etiology, clinical course and outcomes and treatment modalities for mood disorders.

HISTORICAL PERSPECTIVES

• Many ancient cultures (e.g. Babylonian, Egyptian, and Hebrew) believed in the supernatural or divine origin of depression and mania. The Old Testaments states in the Book of Samuel that King Saul's depression was inflicted by an evil spirit sent from the God to torment him.
• Greek medical community form the 5^th century B.C. thorough 3^rd century AD had nondivine point of view regarding depressive and manic states. This represented the thinking of Hippocrates, Celsus and Galen and among others. They strongly rejected the idea of divine origin and considered the brain as the seat of all emotional states. Hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain.
• During the Renaissance, several new theories evolved. Depression was viewed by some as being the result of obstruction of vital air circulation, excessive brooding or helpless situations beyond the individual's control. These strong emotions of depression and mania were reflected in major literary works of the time, including Shakespeare's  King Lear, Macbeth and Hamlet.
• In the 4^th and 5^th centuries BC ,the term melancholia was used by ancient Greeks to describe the dark mood of depression.
• Hippocrates used the term melancholia to describe depression and, mania to describe the mental disturbances in clients. During the second century AD, Arteaeus of Cappadocia described cyclothymia as a form of mental  with alternating periods of depression and mania. For centuries ,melancholia and cyclothymia were regarded to be separate disease entities rather than diverse expression of mood disorders.
• In 1854 ,Jules Faret described a condition called folie circulaire, in which patients experience alternating moods of depression and mania.
• By 1880, four categories of mood disorders existed: mania, melancholia, monomania, and dipsomania.
• In 1882 ,a German psychiatrist, Karl Kahlbaum described melancholia and mania as a continuum of the same illness.
• In 1889, Emil Kraepelin, reinforced Kahlbaum's theory about the continuum of depression. He introduced the category of manic depressive psychosis, citing the most of the criteria now used to establish the diagnosis of bipolar I disorder. He also introduced the category of involutional melancholia, now viewed as a mood disorder that that occurs in late adulthood.
• In the 19^th century ,the definition of mania was narrowed down from the concept of total madness to that of a disorder of affect and action. The old notion of melancholia was refurnished with meaning and emphasis was placed on the primary affective nature of the disorder.

Dates	Events
600BC	Early chronicles describe Nebuchadnezzar as suffering from wild erratic mood (probably mania) followed by profound depression.
300BC	Hippocrates related depression to the humidity of the brain. His theory of body substances ,called humors determined physical and mental health. Depression was blamed on a surplus of melancholy (black bile)
5AD	Attitude about hope changed with the spread of Christianity when St.Paul declared that hope stands with love.
1500s	During the Elizabethan period ,people prided themselves on being melancholic and and came to view it as a superior malady and mark of refinement among  those deeply touched by the paths in life. The  writings of Shakespeare and Robert Burton included depressive themes.
1800s	Dostoyevsky ,Poe and Hawthorne expressed inner anguish despair in the writings. Later poets such as Shelley accepted the fatalistic cynical view of the Greeks. Nietzsche wrote ,Hope is the worst of evils ,for it prolongs the torment of man.
1900s	Winston Churchill, by frequent referral to his " black dog " of depression ,suggested how familiar a companion his despair was.
1930s	ECT was introduced in Rome by two physicians who observed that epileptic client showed no evidence of schizophrenia. Thinking that seizures prevented schizophrenia, they promoted the use of artificially induced seizures to treat schizophrenia and depression.
1950s	Introduction of the first clinically effective antidepressant ,imipramine and MAOIs
1980s	An age of depression exists ,generated by the rising expectations for standards of living after world war II, coming up against the harsh realities of the population explosion, limited resources, inflation, unemployment and the possibility of nuclear warfare. The anxieties of the mid 1960s have given way to despair as a dominant mood. Suicide is a major health problem in U.S.
1990s	The antidepressant Prozac shows  promise in treating depression without having the side effects associated with other antidepressants.
Future	The decade of the brain emerges with an emphasis on biological causes of depression such as disruption in the circadian rhythm, brain dysfunction and the role of genetics. The stigma of depression and mental illness may diminish as biological causes are emphasized and replace the psychological causes of depression. Nurses are challenged to contribute to the expanding knowledge of the biological aspects of the mental illness by the collaborative research with other discipline.

EPIDEMIOLOGY

Major depression is one of the leading causes of disability in the United States. It affects almost 10 percent of the population, or 19million Americans, in a given year. During their lifetimes ,10 to 25 percent of women and 5 to 12 percent of men will become clinically depressed. This preponderance has led to the consideration of depression by some researchers as "the common cold of psychiatric disorders" and this generation as an age of melancholia".

Bipolar affective disorder affects approximately 2.3 million American adults, or about 1.2 percent of the U.S population age 18 and older in a given year (National Institute of Mental Health, 2001).

Gender

Data from the National Comorbidity Survey Replication suggest that the lifetime prevalence of developing major depressive disorder is 16.2%, with twice as many women developing the disorder. The lifetime prevalence of bipolar disorder is about equal for men and women, 1.4% and 1.3%, respectively. Women have a life time prevalence of 21.3% for major depression and 8% for dysthymia, whereas men have a prevalence of only 12.7% for major depression and 4.8% for dysthymia. The incidence of bipolar disorder is roughly equal, with a ratio of women to men of 1.2 to 1.

Age

Several studies have shown that the incidence of depression is higher in young women and has a tendency to decrease with age. The opposite has been found in men , with the prevalence of depressive symptoms being lower in younger men and increasing with age. The average age at onset for a for a first manic episode is the early twenties. The first episode of a mood disorder seems to be occurring at younger ages. The average age for onset of bipolar illness is the mid to late twenties although children and teenagers are now being diagnosed. Although the average age of onset for unipolar depression  has been the middle 30s ,there is some evidence that onset is occurring in younger individuals. The most frequent age of onset for depression is between 25 to 44years.Data indicate that when the onset of depression is at an early age (teens or early 20s) or at 55years or over ,it is usually more prolonged and chronic. Persons presenting with depression that is diagnosed in their early 20s or 30s often report not having depression in their early years. Rates of depression do not significantly increase during menopause. The risk of developing depression and mania increases if there is positive family history for mood disorders.

Sociocultural factors

Results of studies have indicated an inverse relationship between social class and report of depressive symptoms. Bipolar disorder appears to occur more frequently among the higher socioeconomic classes.

Race and culture

Depression seem to occur less frequently in African Americans than in either white or Hispanic groups in U.S. Although depression and mania occurs through out the world ,ethnicity and culture influences the expression of symptoms. For example , Asians describe more somatic symptoms of depression ,whereas people from Western cultures describe more mood and cognitive changes.

In an increasingly stressful society characterized by mobility, family disruptions and economic stressors ,women and younger persons are manifesting depression more than in previous generations. Persons with depression often seeks help from their primary care providers for physical symptoms such as fatigue , insomnia, headache and loss of appetite. Research indicates that primary care providers do not always correctly diagnose depression or treat it appropriately.

Marital status

The highest incidence of depressive symptoms has been indicated in individuals without close interpersonal relationships and in persons who are divorced or separated. When gender and marital status are considered together, the differences reveal lowest rates of depressive symptoms among married men , and the highest among married women and single men.

Seasonality

Many studies revealed two prevalent periods of seasonal involvement: one in spring (March, April and May) and one in the fall(September, October and November). This pattern tends to parallel the seasonal patterns for suicide, which shows a large peak in the spring and a smaller one in October.

TYPES OF MOOD DISORDERS

The DSM IV TR Classification

The DSM IV TR describes the essential features of theses disorders as a disturbance of mood, characterized by full or partial manic or depressive syndrome that cannot be attributed to another mental disorder. Mood  disorders are classified into under two major categories :depressive disorder and bipolar disorders.

DEPRESSIVE DISORDERS

Major depressive disorder

This disorder is characterized by depressed mood or loss of interest or pleasure in usual activities. Evidence will show impaired social and occupational functioning that has existed for at least two weeks ,no history of manic behavior ,and symptoms that cannot be attributed to use of substances or a general medical condition.

Major depressive disorder may be further classified as follows :

1.   Single episodic or recurrent : a single episode specifier is used for an individual's first diagnosis of depression. Recurrent is specified when the history reveals two or more episodes of depression.

2.   Mild, moderate or severe: These categories are identified by the number and severity of symptoms.

3.   With psychotic features : the impairment of reality testing is evident . the individual experiences delusions or hallucinations.

4.   With catatonic features : this category identifies the presence of psychomotor disturbances such as severe psychomotor retardation ,with or without the presence of waxy flexibility or stupor or excessive motor activity. The individual may also manifest symptoms of negativism, mutism, echolalia or echopraxia.

5.   With melancholic features : this is a typically severe form of major depressive episode. Symptoms  are exaggerated. Even  temporary reactivity to usually pleasurable stimuli is absent. History reveals a good respose to antidepressant or other somatic therapy.

6.   Chronic: this classification applies when the current episode of depressed mood has been evident continuously for at least the pat two years.

7.   With seasonal patterns: this diagnosis indicates the presence of depressive symptoms during the fall or winter month. This  diagnosis is made when the number of seasonal depressive episode is substantially higher than the number of nonseasonal depressive episodes  that have occurred over the individuals lifetime.

8.   With postpartum onset : this specifier is used when symptoms of major depression occur within 4weeks of postpartum.

DYSTHYMIC DISORDER:

Individuals with dysthymic disorder describe the mood as sad or "down in the dumps". There is no evidence of psychotic symptoms. The essential feature is a chronically depressed mood for most of the day, more days than not ,for at least 2 years . It is classified into:

1.   Early onset : identifies cases of dysthymic disorder when the onset occurs before age 21 years

2.   Late onset : identifies cases of dysthymic disorder when the onset occurs at age 21 years or older.

Premenstrual dysphoric disorder

The DSM IV TR does not include premenstrual dysphoric disorder as an official diagnostic category ,but provides a set of research criteria to promote further study of the disorder. The essential feature include markedly depressed mood ,marked anxiety ,mood swings and decreased interest in activities during the week prior to menses and subsiding shortly after the onset of menstruation.

BIPOLAR DISORDERS

The bipolar disorder is characterized by mood swings from profound depression to extreme euphoria with intervening periods of normalcy. Delusions or hallucinations may or may not be part of the clinical picture and onset of symptoms may reflect a seasonal pattern.

Bipolar I disorder it is diagnosis given to an individual who is experiencing or has experienced ,a full syndrome of manic and mixed symptoms. The client also may have experienced episodes of depression.

Bipolar II disorders

This diagnostic category is characterized by recurrent bouts of major depression with episodic occurrence of hypomania. The client has never experienced an episode that meets the full criteria for mania or mixed symptomatology.

Cyclothymic disorder

The essential feature of cyclothymic disorder is a chronic mood disorder is a chronic mood disturbance of at least 2years duration involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for either bipolar I or II disorder.

OTHER MOOD DISORDERS

Mood disorders due to a general medical condition

This disorder is characterized by a prominent and persistent disturbance in mood that is judged to be the result of direct physiological effects of a general of a general medical condition. The  mood disturbance may involve depression or elevated ,expansive or irritable mood and causes clinically significant distress or impairment in social ,occupational or other important areas of functioning.

Substance induced mood disorders

The disturbance of mood associated with this disorder is considered to be the direct result of physiological effects of a substance. The mood disturbance may involve depression or elevated ,expansive or irritable mood and cause clinically significant distress or impairment in social ,occupational or other areas of functioning.

ICD 10 classification of mood disorders

The mood disorders are classified as follows :

1.   manic episode

2.   depressive episode

3.   bipolar mood disorders

4.   recurrent depressive disorders

5.   persistent mood disorders( including cyclothymia and dysthymia).

6.   other mood disorders (including mixed affective episode and recurrent brief depressive disorders )

Conclusion:

Depression is also linked to morbidity and mortality when it is associated with other illnesses such as cardiovascular disease. As a result of these serious consequences, there has been ongoing research about the etiology, clinical course and outcomes and treatment modalities for mood disorders.

References :

1. Carson V B. Mental Health Nursing :The Nurse Patient Journet.2^nd ed.Philadelphia : W.B. Suanders Company;2000
2. Fortinash KM, Worret PA .Psychiatric Mental Health Nursing.4^th ed. Philadelphia : W.B. Suanders Company;2008
3. Shives LR .Basic Concepts of Psychiatric -Mental Health Nursing.7^th ed.Philadelphia : Lippincott publications; 2008
4. Sreevani R. A Guide to Mental Health and Psychiatric Nursing. New Delhi:Jaypee Medical Publications ;2004.
5. Mary TC. Psychiatric Mental Health Nursing -Concept of Care 3^rd ed. Philadelphia :F.A. Davis Publishers ;2002
6. Ahuja N .A Short Text Book of Psychiatry 5^th ed. New Delhi: Jayee Medical Brothers Publishers .2002.
7. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers ;1998.
8. Sadock BJ ,Sadock VA. Synopsis of psychiatry :Behavioral Sciences/ Clinical Psychiatry.10^th ed. Philadelphia :William and Wilkinson Publishers;2007.

Introduction

More than 20 chemically distinct opioid drugs are in clinical use throughout the world. In the developed countries ,the opioid drug most frequently associated with abuse and dependence is heroin-a drug that is not approved for therapeutic purposes in the United States.

Profile  of the substance

The term opioid refers to a group of compounds include opium, opium derivatives and synthetic substitutes. Opioid exerts both a sedative and an analgesic effect, and their major medical uses are for the relief of pain, the treatment of diarrhea , and the relief of coughing. These drugs have addictive qualities; that is they are capable of inducing tolerance and physiological and psychological dependence.

Opioids are popular drugs of abuse in that they desensitize an individual to both psychological and physiological pain and induce a sense of euphoria. Lethargy and indifference to environment are common manifestations.

Opioids have been used for at least 3,500years, mostly in the from of crude opium or in alcoholic solutions of opium. Morphine was first isolated in 1806 and codeine 1832. Over the next century, pure morphine and codeine gradually replaced crude opium for medicinal purposes, although nonmedical use of opium still persists in some parts of the world.

The opioid induced disorders as defined by DSM IV TR include opioid intoxication, opioid withdrawal, opioid induced sleep disorders and opiod induced sexual  dysfunction .

Opioid abusers usually spend most of the time in nourishing their habit. They are seldom able to hold a steady job that will support their need. They must therefore secure funds from friend, relatives or whomever they have not yet alienated with their dependency related behavior. They may use illegal means of obtaining funds ,such as burglary, robbery, prostitution or selling drugs.

Methods of administration

It include oral, snorting or smoking and by subcutaneous or smoking and by subcutaneous ,intramuscular and intravenous injections .

They are most effective agents known for the relief of pain. They also induce a pleasurable effect on the CNS. So under close supervision , opioids are indispensible in the practice of medicine.

Historical aspects

Opium is the Greek word for "juice ". In its crude form, opium is a brownish black, gummy substance obtained from the ripened  pods of the opium poppy. References  to the use of opiates have been found in the Egyptian, Greek, and Arabian cultures as early as 3000 B.C. The drug became widely used both medicinally and recreationally throughout Europe during the 16^th and 17^th century. Morphine ,the primary active ingredients of opium, was isolated in1803 by the European chemist Frederich Serturner. Since that time ,morphine ,rather than crude opium ,has been used throughout  the world for the medical treatment of pain and diarrhea. This process was facilitated in 1853 by the development of the hypodermic syringe , which made it possible to deliver the undiluted morphine quickly into the body for rapid relief from pain.

This development also created a new variety of opiates user in the United States: one who was able to self administer the drug by injection. During this time , there was also a large influx of Chinese immigrants from the United States, who introduced opium smoking to this country. By the early part of the 20^th century , opium addiction was widespread.

In 1914 the U.S government passed the Harrison Narcotic Act, which created  strict controls on the accessibility of opiates. Until that time these substances were freely available to the public without a prescription. The Harrison Act banned the use of opiates for other than medicinal purposes and drove the use of heroin underground.

Opioid derivatives

• Morphine
• Heroin
• Hydromorphone
• Oxymorphone
• Levorphanol
• Methadone
• Meperidine (Pethedine)
• Fentanyl
• Codine
• Hydrocordone
• Drocode
• Oxycodone
• Propoxyphene
• Buprenorphine
• Pentazocaine
• Nalbuphine
• Butorphanol

Patterns of use and abuse

The development of opioid abuse and the dependence may follow one of two typical behavior patterns. The first occurs in the individual who has obtained the drug by prescription from a doctor for the relief of a medical problem. Abuse and dependency occur when the individual increases the amount of the substance and frequency of use ,justifying the behavior as symptom treatment . He or she becomes obsessed with obtaining increasing amount of the substance, seeking out several physician in order to replenish and maintain supplies.

The second pattern of behavior associated with abuse and dependency of opioids occurs among individuals who use the drugs for recreational purposes and obtain them from illegal sources. Opioid may be used alone to induce the euphoric effects or in combination with stimulants or other drugs to enhance the euphoria or to counteract the depressant effects of the opioid. Tolerance develops and dependency occurs, leading the individual to procure the substance by whatever means is required to support the habit.

Epidemiology : the number of current heroin users in U.S has been estimated to be between 600,000 and 800,000. The male to female ratio of person with heroin dependence is about 3 to 1.

Neuropharmacology :

The primary effects of the opioid are mediated through the opioid receptors, which were discovered in the second half of the 1970s. the µ -opioid receptors are involved in the regulation and mediation of analgesia, respiratory depression ,constipation and dependence; the k -opioid receptors with analgesia ,dieresis and sedation; and the  δ -opioid receptors possibly with analgesia.

In 1974 , enkaphalin an endogenous pentapeptide with opioid like actions was identified. This led to identification of 3 classes of endogenous opioid with in the brain including the endorphins and enkaphalins. Endorphins are involved in neural transmission and pain suppression. They are released naturally in the body when a person is physically hurt.

The opioids have significant effect on the dopaminergic and noradrenergic neurotransmitter system. The properties of opioids are mediated through the activation of the ventral tegmental area dopaminergic neuron that project to the cerebral cortex and the limbic system.

Heroin is the most commonly abused opioid. It is more potent and lipid soluble than morphine. It crosses the blood brain barrier faster and has amore rapid onset than morphine. Heroin was first introduced as a treatment for morphine addiction .codeine is absorbed easily through GI tract and is subsequently transformed into morphine in the body.

Etiology

Psychosocial factors : opioid dependence is not limited to low socioeconomic classes, although the incidence of opioid dependence is greater in these group than the in higher socioeconomic classes. About 50% of urban heroin users are children of single parents and are from families in which at least one other member has a substance related disorder. Children from such settings are at high risk for opioid dependence ,especially if they also evidence behavioral problems in school or other signs of conduct disorders.

Some behavior patterns seem to be especially pronounced in adolescents with opioid dependence. These pattern is called heroin behavior syndrome. It includes depression, often of an agitated type and frequently accompanied by anxiety symptoms, fear of failure ,use of heroin as an antianxiety agent to mask the feelings of low self esteem, hopelessness, aggression etc.

Biological and genetic factors

Monozygotic twins are more likely than dizygotic twins to be concordant for opioid dependence. A  biological predisposition to an opioid related disorder may also be associated with abnormal functioning in either the dopaminergic or the noradrenergic neurotransmitter system.

Psychodynamic theory

Serious ego psychology thought to be associated with substance abuse. In psychoanalytical literature, the behavior of persons addicted to narcotics has been described in terms of libidinal fixation ,with regression to pregenital ,oral or even more archaic levels of psychosexual development.

DIAGNOSIS

OPIOD DEPENDENCE AND OPIOD ABUSE

DSM IV TR DIAGNOSTIC CRITERIA

It is same as the substance dependence and abuse.

Opioid intoxication

The DSM IV TR defines the opioid intoxication as including maladaptive behavioral changes and some specific physical symptoms of opioid use.  In general ,altered mood, psychomotor retardation, drowsiness, slurred speech and impaired memory and attention suggest a diagnosis of opioid intoxication.

Diagnostic criteria for Opioid Intoxication

1. Recent use of an opioid.
2. Clinically significant maladaptive behavioral or psychological changes (e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that developed during, or shortly after, opioid use.
3. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use:
   1. drowsiness or coma
   2. slurred speech
   3. impairment in attention or memory
4. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Opioid withdrawal

Diagnostic criteria for opioid withdrawal

A.   Either of the following:

1.   cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer)

2.   administration of an opioid antagonist after a period of opioid use

B.   Three (or more) of the following, developing within minutes to several days after Criterion A:

1.   dysphoric mood

2.   nausea or vomiting

3.   muscle aches

4.   lacrimation or rhinorrhea

5.   pupillary dilation, piloerection, or sweating

6.   diarrhea

7.   yawning

8.   fever

9.   insomnia

C.   The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D.  The symptoms are not due to a general medical condition and are not    better accounted for by another mental disorder

The general rule about the onset and duration of withdrawal symptoms is that substances with short duration of action tend to produce short, intense withdrawal syndromes and substances with long duration of action produce prolonged but mild symptoms.

An abstinence syndrome can be precipitated by administration of an opioid antagonist. The symptom can begin within seconds of such an IV injection and peak in about one hour. Opioid craving rarely occurs in the context of analgesic administration for pain from physical disorders or surgery. The  full withdrawal syndrome, including intense craving for opioids usually occurs only secondary to abrupt cessation of use in persons with opioid dependence.

Morphine and heroine : the withdrawal symptoms begin 6 to8 hors after the last dose, usually 1 to 2 week period of continuous use or after the administration of a narcotic antagonists. The withdrawal symptoms reaches it peak during the second or third day and subsides during the next 7 to 10 days, but some symptoms may persists for 6months or longer.

Meperidine: withdrawal symptoms begins quickly, reaches a peak in 8 to 12 hours and ends in 4 to5 days .

Methadone : withdrawal symptoms begins 1 to 3 days after the last dose and ends in 10-14 days.

Symptoms: it includes severe bone aches, profuse diarrhea, abdominal cramps, rhinorrhea, lacrimation, piloerection or goose flesh, yawning, papillary dilatation, hypotension ,tachycardia and temperature dysregulation including hypothermia and hyperthermia. Residual symptoms such as insomnia, bradycardia, temperature dysregulation and a craving for opioids -can persists for months after withdrawal.  Associated features of opioid withdrawal include restlessness, irritability, depression, tremor, weakness, nausea and vomiting. At any time during the abstinence syndrome, a single injection of morphine or heroine eliminates all the symptoms.

Opioid intoxication delirium

It is more likely to happen when opioids are used in high doses ,are mixed with other psychoactive compounds or  are used by a person with preexisting brain damage or CNS disorder like epilepsy.

Opioid induced psychotic disorders :It can begin during opioid intoxication. Clinicians can specify whether hallucinations or delusions are the predominant symptoms.

Opioid induced mood disorders : it can begin during intoxication. the symptom can have manic, depressed or mixed nature ,depending on a persons response to opioids. A person coming to psychiatric attention with opioid mood disorder usually has mixed symptoms ,combining irritability ,expansiveness and depression.

Opioid induced sleep disorder and opioid induced sexual dysfunction

The most common sexual dysfunction is impotence.

Opioid related disorder not otherwise specified

The DSM IV TR includes diagnoses for opioid -related disorders with symptoms of delirium , abnormal mood ,psychosis, abnormal sleep and sexual dysfunction. Clinical situation that do not fit into those will be placed under this category.

Clinical features :

Opioids can be taken orally ,snorted intranasally and injected intravenously or subcutaneously. Opiods are subjectively addictive because of the euphoric high that users experience ,especially those who takes the substances IV. The associated symptoms include a feeling of warmth, heaviness of the extremities, dry mouth, itchy face especially the nose and facial flushing. The initial euphoria is followed by a period of sedation ,known in street parlance as nodding off. Opioid can induce dysphoria, nausea and vomiting in opioid naïve persons.

The physical effects of opioid include respiratory depression ,papillary constriction ,smooth muscle contraction ,constipation ,and changes in blood pressure ,heart rate and body temperature.

Adverse effects

The most common and serious adverse effect of is the potential transmission of hepatitis and HIV through the use of contaminated needles by more than one person.

Persons can develop idiosyncratic allergic reactions to opioids which result in anaphylactic shock, pulmonary edema and death if they do not receive prompt and adequate treatment.

Another adverse effect is an idiosyncratic drug interaction between meperidine and MAOI, which can produce gross autonomic instability, severe behavioral agitation ,coma, seizures and death. Opioids and MAOI should not be given together.

Opioid overdose

Death from an overdose of an opioid is due to respiratory depression. The  symptoms of overdose include marked unresponsiveness, coma, slow respiration ,hypothermia, hypotension and bradycardia. When presented with the clinical triad of coma, pinpoint pupils and respiratory depression ,clinician should consider opioid overdose as a primary diagnosis.

MPTP -induced Parkinsonism

In 1976, after ingesting an opioid contaminated with methylphenyltetrahydropyridine (MPTP), several persons developed a syndrome of irreversible parkinsonism. The mechanism for neurotoxic effect is as follows :MPTP is converted into 1-methyl-4-phenylpyridinium(MPP+) by the enzyme monoamineoxidase and is then taken up by dopaminergic neurons.because MPP+ binds to melanin in sustantia nigra neurons,MPP+ is concentrated in this neurons and eventually kills the cells. PET studies of persons who ingested MPTP but remained asymptomatic have shown a deceased number of dopamine binding sites in the sustantia nigra. This decrease reflects a loss in the number of dopaminergic neurons in that region.

Treatment and rehabilitation

Overdose treatment

• Ensure an adequate airway: tracheopharyngeal secretions should be aspirated, an airway may be inserted.
• The patient should be ventilated mechanically until naloxone is given
• Naloxone is administered IV at a slow rate -initially about .8mg per 70 kg of body weight. Signs of improvement (increased respiratory rate and papillary dilation )should occur promptly. In opioid patient too much naloxone may produce signs of withdrawal as well as reversal of overdose. If no response to the initial dose of ,naloxone administration may be repeated after intervals of a few minutes. The  duration of action of naloxone is short compared with that of many opioids, such as methadone and levomethadyl acetate and repeated administration may be required to prevent recurrence of opiod toxicity.

Medically supervised withdrawal and detoxification

Opioid agents for treating opioid withdrawal

Methadone : it is a synthetic narcotic that substitutes for heroin and can be taken orally. A daily doses of 20 to 80mg is sufficient to stabilize the patient although daily dose of 120mg can be given. The duration of action exceeds 24 hours : thus once a daily dose is enough. Methadone maintenance is continued until the patient can be withdrawn from methadone, which itself causes dependence. An abstinence syndrome occurs with methadone withdrawal  but patients are detoxified methadone more easily than from heroin. Clonidine (.1 to .3mg three to four time a day) is usually given during the detoxification period.

Advantages :

• It frees the persons with opioid dependence from using injectable heroin and reduces the chance of spreading HIV infection through contaminated needles.
• methadone produces minimal euphoria and rarely causes drowsiness or depression when taken for a long time
• It allows patients to engage in gainful employment instead of criminal activity.

Disadvantage : patient remain dependent on methadone.

Other opioid substitutes

Levomethadyl (LAAM): it is an opioid agonist that suppresses opioid withdrawal. It  is no longer used because some patients developed prolonged QT interval with arrhythmias

Buprenorphine: it can be dispensed on an outpatient basis but prescribing physician must  demonstrate that they have revived special training in its use. It is effective in thrice weekly dosing . daily use of 8-10mg appears to reduce heroin use. After repeated administration ,it blocks the subjective effect of parenterally administered opioid such as heroin or morphine. A mild withdrawal syndrome occurs if the drug is abruptly discontinued after chronic administration.

Opioid antagonists

Opioid antagonists block the effects of opioids. They do not exert narcotic effects and do not cause dependence. Opioid antagonists include naloxone which is used to treat opioid overdose because it reverse the effects of narcotics and naltrexone .

The theory for using an antagonists is that it blocks the agonist effect ,particularly euphoria, discourages the person with opioid dependence from substance seeking behaviors and thus deconditions  this behavior.

Psychotherapy

Individual psychotherapy, behavioral therapy ,cognitive behavioral therapy ,family therapy, support groups(Narcotic Anonymous, NA) and social skill training are effective for specific patients.

Therapeutic community

Therapeutic communities are residences in which all members have a substance abuse problem. The goal are to effect a complete change of life style, develop personal honesty, responsibility and useful social skills and it eliminate an antisocial attitude and criminal behavior.

Education and needle exchange

Encourage the person to abstain from opioid. Education about the transmission of HIV must receive equal attention. persons with opioid dependence  who use IV or subcutaneous

Narcotic Anonymous

Narcotic Anonymous is a self help group of abstinent drug addicts modeled on the 12 step principles of Alcoholic Anonymous (AA). the outcome for patients treated in 12 step program is good.

References :

1. Mary TC. Psychiatric Mental Health Nursing -Concept of Care 3^rd ed. Philadelphia :F.A. Davis Publishers ;2002
2. Ahuja N .A Short Text Book of Psychiatry 5^th ed. New Delhi: Jayee Medical Brothers Publishers .2002.
3. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers ;1998.
4. Sadock BJ ,Sadock VA. Synopsis of psychiatry :Behavioral Sciences/ Clinical Psychiatry.10^th ed. Philadelphia :William and Wilkinson Publishers;2007.

Introduction

It is one of the most heavily used  addictive in the United States and around the world. It causes lung cancer, emphysema and cardiovascular diseases .

Epidemiology

Age and gender

• The WHO estimates there are 1 billion smokers world wide and they smoke 6trillion cigarettes a year. The WHO also estimates that tobacco kills more than 3 million persons each year. The rate of quitting smoking has been highest among well-educated white men and lowest among women, blacks, teenagers and those with low levels of education.
• Tobacco is the most common form of nicotine. It is smoked most commonly in cigarettes, cigars , chewing tobacco and in pipes. About 3% of all persons in the United States currently use snuff or chewing tobacco and 6% of young adults ages 18 to 25 use those forms of tobacco.
• Currently about 25% of American smoke , 25% are former smokers and 50% have never smoked cigarettes. The mean age of onset of smoking is 16 years and few person start smoking after 20.
• More than 75% of smokers have tried to quit and about 40% try to quit each year. On a given attempt, only 30% remain abstinent for even 2 days,and only 5-10% stop permanently.
• According to DSM-IV-TR , around 85% of current daily smokers are nicotine dependent. Nicotine withdrawal occurs in about 50% smokers who try to quit.

Education: Of adults who had not completed high school ,37% smoked cigarette, whereas only 17% percent of college graduate smoked.

Psychiatric patients : Approximately 50% all psychiatric outpatients, 70% of outpatients with bipolar I disorder, almost 90% of outpatients with schizophrenia and 70% of substance use disorder patient smoke.

Patients with depressive disorder or anxiety disorder are less successful in their attempt to quit smoking than other persons.

Death : Tobacco use is associated with approximately 4000,000 premature deaths each year in the United States-255 of all deaths. Researchers have found that 30% of deaths in the United States are caused by tobacco smoke.

Cause of death : it include chronic bronchitis and emphysema (51,000 deaths), bronchogenic cancer (106,000 deaths) ,35% of MI(115,00deaths),cereberovascular disease ,cardiovascular disease and lung cancer. The increased use of chewing tobacco and snuff has been associated with the development of oropharyngial cancer. Smoking cause the cancer of the lung, upper respiratory tract, esophagus , bladder and pancreas and probably of the stomach .liver and kidney.

NEUROPHARMACOLOGY

The psychoactive component of tobacco is nicotine which affects the CNS. About 25% of the nicotine inhaled during smoking reaches blood stream, through which nicotine reaches the brain with in 15 seconds.  The half life of the nicotine is 2 hours. Nicotine is believed to produce its positive reinforcing and addictive properties by activating the dopaminergic pathway projecting from the ventral tegmental area to the cerebral cortex and limbic system. It also causes an increase in the concentration of norepinephrine and epinephrine and an increase in the release of vasopressin, beta endorphins,ACTH and cortisol. Theses hormones are thought to cause stimulatory effects of nicotine on the CNS.

DIAGNOSIS

The DSM IV TR lists three nicotine related disorders . theses are

• Nicotine dependence
• Nicotine withdrawal
• Nicotine related disorders not otherwise specified

Nicotine dependence

DSM IV TR diagnostic criteria

Same  as that of the criteria for substance dependence

Dependence on nicotine develops quickly because it activates the ventral tegmantal area of depaminergic system. Many studies proved  a genetical predisposition to nicotine dependence. Person are likely to smoke if their parents or siblings smoke and serve as role models.

Nicotine withdrawal

DSM IV TR diagnostic criteria

1. Daily use of nicotine for at least several weeks.
2. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four (or more) of the following signs:
   1. dysphoric or depressed mood
   2. insomnia
   3. irritability, frustration, or anger
   4. anxiety
   5. difficulty concentrating
   6. restlessness
   7. decreased heart rate
   8. increased appetite or weight gain
3. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Withdrawal symptoms can develop within 2 hours of smoking the last cigarette: they generally peak in the first 24 to 48 hours and and can last for weeks or months.

Symptoms : the common symptoms are an intense craving for nicotine ,tension, irritability, difficulty concentrating, drowsiness and paradoxical trouble sleeping, decreased heart rate and blood pressure, increased appetite and weight gain, decreased motor performance and increased muscle tensions.

Nicotine related disorders not otherwise specified

Nicotine related disorders not otherwise specified is a diagnostic category for nicotine-related disorders that do not fit into one of the categories discussed above. Such diagnoses may include nicotine intoxication, nicotine abuse, mood disorders and anxiety disorders associated with nicotine use.

CLINICAL FEATURES

Behaviorally it produces improved attention, learning, reaction time and problem solving ability. It also lifts their mood ,decreases tension and lessens depressive feelings. Studies proved that short term nicotine exposure increases the cerebral blood flow without changing cerebral oxygen metabolism but long term exposure decreases the cerebral blood flow. It also acts as a skeletal muscle relaxant.

ADVERSE EFFECTS

Nicotine is highly toxic alkaloid. Doses of 60mg in an adult are fatal secondary to respiratory paralysis. Doses of .5 mg are delivered by smoking an average cigarette.

Signs and symptoms:

In low doses the signs and symptoms include nausea ,vomiting, salivation ,pallor (due to peripheral vasoconstriction ) ,weakness, abdominal pain(caused by increased peristalsis),diarrhea, dizziness, headache ,increased blood pressure ,tachycardia, tremors and cold sweats.

Toxicity is also associated with an inability to concentrate , confusion and sensory disturbances.

Nicotine is also associated with a decrease in the user's amount of rapid eye movement sleep.

Tobacco use during pregnancy causes increased incidence of low birth weight babies and an increased incidence of newborns with persistent pulmonary hypertension.

Health benefits of smoking cessation

• It increases the life span compared to those continue to smoke
• Decreases the risk for lung cancer ,MI, cerebrovascular diseases and chronic lung disease.
• Women who stop smoking before or during the first trimester reduce their risk for having LBW babies.

TREATMENT

Psychiatrist should advise all patients to quit smoking. Gradual cessation is preferred over abrupt cessation .brief advice should focuses on the need for medication or group therapy, weight gain concern ,high risk situation ,making cigarettes unavailable and so forth.

PSYCHOSOCIAL THERAPIES :

Behavior therapy is the most widely accepted and well proved psychological therapy for smoking. Skill training and relapse prevention identify high risk situations and plan and practice behavioral or cognitive coping skills for those situations in which smoking occurs.

Stimulus control involves eliminating cues for smoking in the environment.

Aversive therapy has smokers smoke repeatedly and rapidly to the point of nausea that associates smoking with unpleasant rather than unpleasant sensation. To be effective it requires a good therapeutic alliance and patient compliance.

HYPNOSIS: Some patients benefits from a series of hypnotic sessions. Suggestions  about the benefits of not smoking are offered and assimilated into the patients cognitive framework as a result . posthypnotic suggestions that cause cigarettes to taste bad or to produce nausea when smoked are also used.

PSYCHOPHARMACOLOGICAL THERAPIES

Nicotine replacement therapies

All nicotine therapies double the cessation rates because they reduce the nicotine withdrawal. These therapies can also be used to reduce withdrawal in patients on smoke free ward.

Replacement therapies use a short period of maintenance of 6 to 12 weeks often followed by a gradual reduction period of another 6 to 12 weeks.

Nicotine polacrilex gum (Nicorette) is an OTC product that release nicotine via chewing and buccal absorption.

Dose: A 2mg variety for those who smoke fewer than 25 cigarettes and 4mg variety for those who smoke more than 25 cigarettes a day are available. Smokers are to use one to two pieces of gum per hour up to maximum 25 pieces per day after abrupt cessation. Acidic beverages(coffee, tea, soda and juice) should not be used before during or after gum use because they decrease absorption. Adverse effects are minor include bad taste and sore jaws. About 20% of the people who quit use the gum for long periods and 2%use it for longer than one year. Long tern use does not cause any harmful effects.

Nicotine lozenges (Commit)

Dose: available in 2mg and 4mg. Generally 9 to 12 lozenges a day are used during the first 6weeks with decrease in dosage there after

Use: They are useful for patients who smoke cigarette immediately on awakening. They  offer the highest level of nicotine of all nicotine replacement products.

Method of administration : users suck the lozenges until it dissolved and not swallow it.

Side effects : insomnia , nausea, heartburn, headache and hiccups.

Nicotine patches

Thses are also sold OTC, are available in a 16 hours no-taper preparation(Nicotrol) and a 24 or 16 hours tapering preparartion (Nicoderm CQ).

Method of administration: patches are administered each morning and produce blood concentration about half those of smoking.

Compliance is high and the only major adverse effect are rashes and with 24 hour wear , insomnia. After 6 to 12 weeks ,the patch is discontinued because it is no for long term use.

Nicotine nasal spray(Nicotrol) :available only by prescription ,produces nicotine concentrations in the blood that are more similar to those from smoking a cigarette and is helpful for heavily dependent smokers. The spray causes rhinitis, watering eyes and coughing more than 70 percent patients.

Nicotine inhaler : it designed to deliver nicotine to the lungs .it delivers 4mg per e and resultant nicotine levels are low. Major advantage is that it provides a behavioral substitute for smoking. It  doubles the quit rate. Theses devices requires frequent puffing -about 20 minutes to extract 4mg of nicotine. It has got minor adverse effects.

NON-NICOTINE MEDICATIONS : it is useful to those smokers who object philosophically to the notion of replacement therapy and smokers who fail replacement therapy. Bupropion which is an antidepressant is used as  non nicotine medication.

Dose: it is started at 150 mg per day for 3days and increased to 150 mg twice a day for 6 to 12 weeks. Daily dosage of 300 mg doubles the quit rates in smoker with or without a history of depression.

Adverse effects : insomnia, nausea

Second line of drug is Nortrypyline. It is found to be effective in smoking cessation.

Clonidine (Catapres) decreases sympathetic activity form the locus ceruleus and it decreases the withdrawal symptoms. Whether given as a patch or orally, .2 to .4 mg a day of clonidine appears to double the quit rates.  It is not much effective as other drugs. It causes drowsiness and hypotension.

Some patients benefit from benzodiazepine therapy (10 to 30 mg per day) for the first 2 to 3 weeks of abstinence.

A nicotine vaccine that produces nicotine specific antibodies in the brain is under investigation at the National Institute on Drug Abuse (NIDA)

Combined psychosocial and pharmacological therapy: increases quit rates over either therapy alone.

Smoke free environment

Secondhand smoke can contribute to lung cancer death and CAD in adult nonsmokers.  Two national health objectives for 2010 are to reduce cigarette smoking among adults to 12% and proportion of nonsmoker exposed to environment tobacco smoke to 45%.

Involuntary exposure to secondhand smoke is common public health hazard. Ban on smoking in publics reduces exposure to secondhand smoke and the number of cigarettes smoked by the smokers.

 

References :

1. Mary TC. Psychiatric Mental Health Nursing –Concept of Care 3^rd ed. Philadelphia :F.A. Davis Publishers ;2002
2. Ahuja N .A Short Text Book of Psychiatry 5^th ed.New Delhi: Jayee Medical Brothers Publishers .2002.
3. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry .9th ed.Hong Kong: William and Wilkinson Publishers ;1998.
4. Sadock BJ ,Sadock VA. Synopsis of psychiatry :Behavioral Sciences/ Clinical Psychiatry.10^th ed.Philadelphia: William and Wilkinson Publishers;2007.

 

INTRODUCTION

Aging is not merely the passage of time. It is the manifestation of biological events that occur over a span of time. It is important to recognize that people age differently. The aging body does change. Some systems slow down, while others lose their "fine tuning." As a general rule, slight, gradual changes are common, and most of these are not problems to the person who experiences them. Sudden and dramatic changes might indicate serious health problems.

BIOLOGICAL ASPECT OF AGING

Individuals are unique in their psychological and physical aging process. As the individual ages, there is a quantitative loss of cells and changes in many of enzymatic activities within cells resulting in a diminished responsiveness to biological demands made on the body. Age related a change occurs at different rate in different people.

NERVOUS SYSTEM

• The brain atrophies as a result of aging process. The brain weight decreases, decrease in enzymes, protein and lipids in brain tissue.
• There is shrinkage of large neurons resulting in loss of large neurons with an increase in smaller neurons.
• There is alterations in the amount for some neuro-transmitters.
• Clinical changes due to the above are decreased sensation of vibrations(particularly in legs), less brisk deep tendon reflexes with ankle reflex absent entirely and a decreased ability for upward gaze.
• Functional changes include slowing of response to tasks and the increase in time to recover from physical exertion
• Cognitive changes include memory loss, decrease in perceptual ability and decrease in proficiency.

SENSORY CHANGES

1. Eyes

• The eye's external changes give evidence of advancing age. These changes result from loss of orbital fat, loss of elastic tissue and decreased muscle tone.
• The skin around the eyes darkens and wrinkles referred to as "crow's feet" appear.
• Xanthomas(cutaneous deposits of lipid material) found at the inner portion of the lid; these may indicate elevated blood lipid levels.
• The cornea flattens which reduces the refractory power
• The retina of older individual becomes thinner because of fewer neural cells and receives only 1/3^rd of the amount of light that of a younger person. Due to this problem in reading, not able to see in dim light and also have difficulty in colour perception.
• The lens of the eye loses its elasticity and increases in density

2. Ear

• Cerumen gland are reduced in number dry and hard ear wax, along with itching.
• Degenerative changes occur in ossicles contributing to hearing loss
• Loss of cochlear hair cells leading to hearing loss; Inner ear changes affect the auditory processing system leading to auditory processing disorder and a peripheral hearing sensitivity loss
• Presbycusis is the term used to describe hearing loss associated with normal aging.

3. Taste and smell

• Very rarely the capacity to smell diminishes;
• Taste perception and taste discrimination decreases as the age advances

INTEGUMENTARY SYSTEM

• Systemic decrease in circulation, loss of cells and loss of elastic collagen fibers and muscle mass.
• The number of pressure and light touch sensors decreases with age
• Subcutaneous fat atrophies on the face, hands, shins and soles; whereas it hypertrophies on the abdomen (in men0 and thighs(in women).
• Immune, vascular and thermoregulatory responses of the skin decrease with age.
• Loss of hair colour and thinning of pubic, axillary and scalp hair.

CARDIOVASCULAR SYSTEM

• Collagen and lipid deposits increase intercellularity in the heart muscle
• Lipofuscin, a yellow-brown granular material accumulates in the myocardial cell.
• Valves of the heart becomes thicker and more rigid as a result of calcification
• The SA node is infiltrated by fat and connective tissue resulting in a decrease in the heart's ability to regulate the rate of SA node, also causing a slowing of electrical impulses through the AV tissue.
• There is 10% decrease in the number of pacemaker cells in the SA node by age 75 years. Many of the arrhythmias seen in the older person are a result of either the decrease in pacemaker cells or the infiltration of fat in the SA node.

RESPIRATORY SYSTEM

• Degeneration of the intervertebral discs leading to development of kyphosis and scoliosis
• The trachea and large bronchi are also increased in diameter because of the calcified cartilage changes
• The muscles involved in respiration weaken with age. It results in less forceful contraction which decreases inspiratory and expiratory effort.
• The combination of increased stiffness of the chest wall and decreased muscle strength results in less efficient breathing.
• Older people depend more on accessory abdominal muscles to compensate for weakened thoracic muscles.

MUSCULOSKELETAL SYSTEM

• Bone resorption takes place without the successful formation of new bone mass leading to gradual  bone loss.
• Loss of trabecular bone leads to compression fractures in vertebral column.
• Reduction in cortical thickness and increased porosity results in progressive cortical thinning.
• In aging, the increased parathyroid hormone, decreased vitamin D and calcitonin also play role in calcium loss in older people.
• In women, estrogen deficiency, calcium malabsorption, lifestyle factors (calcium intake and exercise) can result in bone loss.Aging brings decline in numbers of muscles resulting in reduced muscle mass.
• The muscle strength also reduces especially due to lack of exercise.

URINARY SYSTEM

• In men, BPH is associated with aging leads to urinary incontinence (dribbling).
• In women, estrogen deficiency causes changes in the squamous epithelium of the distal urethral and vaginal wall, a decrease in the vaginal muscular tone and vascular profusion. These changes contribute to urinary incontinence.
• Increasing age is also associated with an increase in involuntary bladder contractions, a reduction in bladder capacity and an increase in residual volume. These contribute to development of incontinence in older adults.
• Weak pelvic muscles causes stress incontinence.

GASTROINTESTINAL SYSTEM

• Teeth become brittle; there is resorption of bone in the jaw leading to loosening of teeth, increased infections of teeth and gums and eventual loss of teeth.
• Difficult to chew food because of loose teeth.
• Common bile duct undergo progressive dilatation with age
• Presence of gall stones increases with age.
• Liver weight and size decreases with age
• There is decrease in number of hepatic cells and as a result, a diminished capacity for metabolism of drugs and hormones.

REPRODUCTIVE SYSTEM

1. Changes in women

• Menopause begins between the ages of 45 to 50 years. The cessation of ovarian secretion of estrogen and progesterone is the major physiologic event of menopause. Women may experience hot flashes due to vasomotor instability. Also another associated feature of menopause is bone loss leading to osteoporosis.
• Decrease in estrogen production leads to reduced vaginal lubrication, the vaginal mucosa becomes thin and the vagina shortens in length and width. Due to this reason, the sexual arousal is reduced which results in painful intercourse and vulvo-vaginitis.

2. Changes in men

• Erectile ability undergoes changes. Takes longer time for erection, amount of semen is reduced and the intensity of ejaculation is lessened.
• It is not clear that whether the increase in impotence is age related.

PSYCHOLOGICAL ASPECTS OF AGING

Memory functioning

• Short term memory deteriorate with age, long term memory does not show similar changes.
• A well educated and mentally active person does not exhibit such changes in faster rate.
• The time required for memory scanning is longer for both recent and remote recall among older people.
• This can be attributed to social or health factors (stress, fatigue, illness), but it can also occur with certain physiological changes due to aging. (decreased blood flow to the brain)

Intellectual functioning

• Fluid abilities or abilities involved in solving novel problems, tend to decline from adult period to old age.
• High degree of regularity in intellectual function present on most of the old age people
• Intellectual abilities of older people do not decline, but do become obsolete.
• Their formal educational experience is reflected in their intelligence performance

Learning ability

• The ability to learn is not decline by age.
• The slowing of reaction time with age and over arousal of central nervous system are noted in old age. It may lead to lower level of performance in tasks which requires high efficiency.
• Ability to learn continue throughout the life, although strongly influenced by personal interests and preferences.
• Accuracy of performances diminishes.

Adaptation to the tasks of ageing

1.       Loss and grief

• By the time individuals reach 60-70 yrs of age , they have experienced numerous losses, and mourning has become a life long process.
• It is impossible for some of the older age people to complete the grief process in response to one loss before the other loss occurs.
• Because the Grief is cumulative, this can result in bereavement over load.
• This can further predispose to depression.

2.       Attachment to others

• The need for attachment is consistent through out the life span
• Well being of senior citizens can be contributed through socialization and companionship.

3.       Maintenance of self identity

• Self concept and self identity appears to remain stable over life time.
• Factors which contribute to good psycho social adjustment are sustained family relationships, maturity of the ego defenses, absence of depressive disorder and absence of alcoholism.

4.       Dealing with death

• Death anxiety among the elderly is more of a myth than reality
• The feeling of abandment, pain and  loss may leads to fear or anxiety in elderly

5.       Psychiatric disorders

• The later life constitute a time of  especially high risk for emotional distress
• Dementia, depressive disorders, delirium, sleep disorders etc are the most common psychiatric illness seen among elderly.

SOCIOCULTURAL ASPECTS OF AGING

• Old age brings many important  socially induced changes, some of those changes have the potential for negative effect on both the physical and mental well being of older persons
• They want protection from hazards and weariness of every day tasks
• They want to treated with respect and dignity and also want to die with respect and dignity
• In developing countries and Asian countries the aged are awarded a position of honor, that place emphasize on family cohesiveness
• In industrialized countries many negative stereotyped perspectives on aging still persisting, aged are always tires or sick, slow and forgetful, isolated and lonely, unproductive etc
• Emplacement is one of the area where the aged faces discrimination. Although compulsory retirements has been eliminated, discrimination still persist in hiring and promoting the aged employees.
• The status of elderly may improve with time as the number of elder person increases world wide.

SEXUAL ASPECTS  OF AGEING

PHYSICAL CHANGES

a) Changes in female

• Menopause may begin anytime during the 40s or early 50s
• Gradual decline in the functioning of the ovaries and subsequent reduction in the production of estrogen.
• The walls of the vagina become thin and inelastic and vaginal lubrication decreases.
• Orgasmic uterine contractions become spastic.
• All these changes result in  vaginal burning, pelvic aching, irritability etc
• In some women these changes result in avoidance of sexual intercourse
• These symptoms  are more likely to occur with infrequent intercourse of only one time a month or less
• Regular and more frequent sexual activity result in a greater capacity for  sexual performance

b) Changes in male

• Testosterone production decline gradually as the age increases
• As a result of these hormonal changes the erection takes place slowly and requires more genital stimulation to achieve.
• The volume of ejaculate decreases and the force of ejaculation lessens
• The testis become smaller, but most men continue to produce viable sperm well in to old age.

SEXUAL BEHAVIOUR IN ELDERLY

• Sexual activity can continue and well preserve till the age of late 70s and 80s for both males and females who have regular opportunities for sexual expression
• As the sexual practices continues frequently, the sexual capacity can prolongs
• Studies reveal that for healthy men and women with healthy partners, sexual activity will probably continue throughout life if they had a positive attitude about sex when they were young.

REFERENCES

1. Mary M B, Mary B W. Gerontologic Nursing. Care of the Frail Elderly. Mosby Year Book. . Philadelphia .2002
2. Burke MM, Walsh MB . Gerontologic nursing. 2^nd ed. Mosby; Philadelphia:1997.
3. Townsend MC. Psychiatric mental health nursing. 3^rd edn. FH Davis publishers. Philadelphia.  2007.
4. Lewis SL, Heitkemper M M. Medical Surgical Nursing- Assessment and Management of problems. Mosby publishers. Philadelphia. 2007.